BED SITE TEACHING

TUTORS : dr.Rizal
Daulay,Sp.OT
CASE REPORT
IDENTIFICATION

Name : Mrs. Azizah
Sex : Female
Age : 38 Years Old
Address : Jl. Tangga Takat
Status : Married
Occupation : Housewife
Religion : Moslem

ANAMNESIS
(Autoanamnesis)
Chief of complain
The patient admitted pain
on right wrist and numb
sensation on indeks
finger, middle finger, ring
finger.
She admitted there is pain in
her right wrist when her age
was around 20, the pain
spread from her wrist to upper
arm. 1 year ago the pain
become worse and there is a
numbness sensation on middle
finger.

Within in a few month the
numbness sensation also felt
on index finger and ring finger.
The pain and numbness
sensation was more
noticeable at night and when
she grasping something. She
often woke up in the middle of
night just to shake her hand.
Her job is a weaver.
Past medical history
The patient never had medical treatment
Before

History of present illness
Hypothyroidism (-), arthritis (-), DM (-) ,
Trauma (-)

operating History
The patient never had surgery before
PRIMARY SURVEY
A : clear

B : Spontan, RR 18x/1

C : regular pulse, frequency 69x/1, warm
extremities, capiler refilling <2, BP: 110/70
mmHg

D : Alert, GCS 15, pupil isokor, light refleks +/+

E : Temp 36,4

SECONDARY SURVEY
Head: Normocephal

Eyes: The conjunctiva was not anemic, not
jaundiced sclera

Nose, ears, mouth: No abnormality

Neck: JVP 5-2 cm H2O

thoracic:
Lung:
Inspection: Symmetric (static and dynamic)
Palpation: left = right fremitus
Percussion: Sonor
Auscultation: Normal Vesicular, ronkhi (-)

Cor :
Inspection: Ictus not visible
Palpation: Ictus palpable 1 finger medial
LMCS RIC V
Percussion: The boundaries of the heart
within normal limits
Auscultation: regular rhythm, noisy (-)

abdomen:
Inspection: distension (-)
Palpation: Supple, liver and spleen not
palpable
Percussion: Timpani
Auscultation: bowel sound (+) Normal
Extremity: warm extremities
Superior: injury
Inferior: normal

Right Wrist
Look : discolouration (-), swelling (-) ,
contractur (-)
feel : temperature normal, tenderness
(+), normal sensorik, pulss (+)
Move :
Active: wrist: flexion 60 ,extension 50 ,
abduction 35 , adduction 20
Left Wrist
Look : discolouration (-), swelling (-) ,
contractur (-)
feel : temperature normal, tenderness (+),
normal sensorik, pulss (+)
Move :
Active: wrist: flexion 60 ,extension 50 ,
abduction 35 , adduction 20
Right hand
Look : discolouration (-), swelling (-)
Athrophy (+) thenar muscle
feel : flabby
Move :
Phalanges: making a fist, , finger extension,
abduction, adduction : normal

Left hand
Look : discolouration (-), swelling (-)
Athrophy (-)
feel : tenderness
Move :
Phalanges: making a fist, , finger
extension, abduction, adduction :
normal

Tests
Phalens manuver (+)
Tinels sign (-)
Durkan test (+)
Hematologi
Hb : 11,8 g/dl N: 11,7-15,5 g/dl
Lekosit:7600/cmm N:4000-11000/cmm
Trombosit: 252.000 N:200.000-400.000/uL
Hematokrit: 38% N: 35-47%
Golongan darah:A, rh+
Clooting time :8 N: <15 menit
Bleeding time: 2 N: 1-6 menit
BSS: 79mg/dl N:60-120 mg/dl
Therapy
Splints
Corticosteroids
Surgery : Release of the transverse carpal
ligament
THANK YOU :D